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In recent years, a palliative approach for patients with cancer has become increasingly focussed on allowing patients to be cared for and to die at home (Thomas 2008). In these circumstances, families and carers are often involved in providing extensive and time-consuming care for seriously ill family members. Research has shown that the experience of caregiving should be seen as having both positive and negative dimensions, with caring relationships no longer characterised as persistently burdensome and unrewarding (Cooper et al. 2006). Whilst palliative home care is often in line with patients’ and families’ wishes and has established positive dimensions, the all encompassing nature of providing home care for a close relative can leave family members with little time to fulfil their own needs (Hudson & Payne 2008). Bereavement following the death of a close relative is associated for most with a period of intense suffering, adjustment can take months or years and is subject to substantial variations between individuals (Stroebe et al. 2007). Palliative care aims to improve the quality of life of patients and families who face life-threatening illness, by providing a range of support from the point of diagnosis to the end of life and bereavement (WHO 2008). As such, a palliative approach reaches beyond care of the patient and aims to support bereaved families and carers during the death of their relative and through subsequent bereavement. The needs of bereaved families and carers are various and complex and should be recognised as requiring dedicated research attention (Stroebe et al. 2007). This study by Cronfalk et al. (2009) addresses this important area of palliative cancer care and aims to explore how bereaved family members in Sweden experience soft tissue massage in the first four months after the death of a relative.

Conducting research in palliative care and with bereaved family members can present ethical and methodological challenges and clearly requires a sensitive approach (Sheldon & Sargeant 2007). Sampling can present particular difficulties and achieving a representative sample in this population can prove problematic. In the study by Cronfalk et al. bereaved relatives were recruited from a large palliative care unit in Sweden, following the death of a family member. Study-related information and an invitation to participate were included alongside general information about bereavement and grief that was sent to all relatives following the death of a family member. Participants were self-selected to the extent that sampling was based on positive responses from participants. Whilst this method of recruiting participants is practicable and ethical in this population, it does raise questions regarding selection bias and the representativeness of the sample. A disadvantage of self-selection in an intervention study of this kind is that participation may be to a certain extent dictated by an interest in the intervention offered. A participant enthusiastic about massage therapies would presumably to be more likely to participate than a participant sceptical of soft tissue massage or complementary therapies in general. Any bias in participation may influence the representativeness of the data that these participants provide. Limitations relating to sampling have been reported in other studies involving the recruitment of bereaved carers (Addington-Hall & McCarthy 2001). It has been suggested that bereaved family members who volunteer to participate in research may do so simply from a need to share their grief with someone, or for the company of someone to talk with (Vale-Taylor 2009). Whilst this in itself does not necessarily confound any data collected, it should be considered that the population who choose to participate in bereaved family member research may not be fully representative of the whole population of bereaved family members.

Complementary therapies have received increasing attention in the palliative care literature in recent years (e.g. Bilhult & Dahlberg 2001, Bilhult et al. 2007). Whilst many authors remain sceptical over the effectiveness and value of complementary therapies (Bender 2008, Watson 2008), others have provided convincing evidence for their efficacy (Carter & Mackreith 2008). Massage therapies have been shown to have positive effects on heart rate and blood pressure (Fakouri & Jones 1987, Meek 1993) and have been shown to improve mood and reduce stress (Goodfellow 2003). Despite this evidence, relatively few well-controlled studies have systematically examined the effects of massage to provide evidence-based support for massage therapies (Goodfellow 2003). The current study adds to the evidence base for massage by using a qualitative interview methodology to examine participants’ experience of soft tissue massage in the first four months of bereavement. In recent years, qualitative methods have become increasingly popular in health service research and particularly in palliative care research. There is increasing recognition amongst academics and health professionals that many processes of health care cannot necessarily be evaluated through use of traditional quantitative research methods, as they are unable to provide adequate insight into the experiences or perceptions of those involved (Crossley 2007). This study provides valuable data on participant experience and provides an ideal starting point for a more rigorous evaluation of soft tissue massage in bereaved relatives. A criticism sometimes levelled at complementary therapies concerns the lack of high-quality empirical evidence to support their use (Bender 2008, Watson 2008). Whilst the findings from this study do not provide substantial evidence that soft tissue massage improves outcomes or assists the grieving process, the evidence does suggest soft tissue massage is well received by bereaved family members and constitutes a positive experience for most. As such, a more rigorous well-controlled systematic assessment of outcomes associated with early intervention soft tissue massage would provide the necessary evidence to support, or otherwise, the use of soft tissue massage in bereaved family members.

In discussing the findings from this study, the authors state that soft tissue massage in bereaved relatives became a source of consolation and help in learning how to restructure life following the death of a loved one. This finding was derived from four themes that emerged from the data: (1) a helping hand at the right time, (2) something to rely on, (3) moments of rest and (4) moments of retaining energy. In identifying these themes, the authors have highlighted many of the emotions and experiences commonly associated with the grieving and bereavement process. However, it should be noted that there is no single ‘correct’ or ‘true’ theories that explain the experience of loss or account for the emotions, experiences and cultural practices that characterise grief and mourning (Joanna Briggs Institute 2006).

The authors report that soft tissue massage was experienced as satisfying a need for hope and comfort and provided a helping hand as relatives struggled to grasp the content of their loss. The experience of soft tissue massage in these circumstances was clearly positive and provided participants with the means to satisfy components of their grief. As there was no control group in this study, nor a placebo intervention, it is difficult to be convinced by the argument that the hope and comfort ascribed to soft tissue massage was not a mere outcome of a regular structured interactive meeting with a health care professional. As one of the participants quotes ‘I just felt I needed to do something to get rid of the pain’. Whilst soft tissue massage was experienced positively, we are unable to assess whether the positive effects of hope and comfort were attributed to the soft tissue massage or whether they were a mere consequence of a structured session with another person aware of their grief.

The authors also state that soft tissue massage was experienced as something to rely on at a time of great personal change and upheaval. Although the massage sessions were credited with providing structure and stability during this difficult period, it should be acknowledged that alternative structured sessions could potentially have satisfied the needs of reliability and structure to an equal extent. Previous research has identified that positive coping strategies during bereavement can be strengthened and supported, and interventions that demonstrate an empathetic presence and a caring professional have been found to be the most helpful (Kaunonen et al. 2000). Eakes et al. (1998) suggested that the most beneficial interventions include taking time to listen, offering support, and recognising and focusing on feelings. Whilst a regular massage session with a trained professional would clearly fulfil the above criteria for an effective intervention, alternative support interventions such as a telephone call, grief support, or bereavement therapy may be found to offer the same benefits as soft tissue massage. A well-controlled comparative evaluation of these modes of support would allow a reliable assessment of the value of soft tissue massage and would enable us to examine whether the positive effects attributed to soft tissue massage are specific to the massage or are a more general consequence of a structured interaction with a professional.

In this study, soft tissue massage was also experienced as something that allowed moments of rest and of retaining energy. Reactions to bereavement amongst close relatives of the deceased can include fatigue, energy loss and exhaustion (Stroebe et al. 2007). Opportunities for bereaved relatives to reduce fatigue and improve levels of energy should therefore be an important component of any bereavement intervention. The soft tissue massage intervention in the current study comprised a 25-minute massage session, followed by a 30-minute rest period. The massage was performed in silence for the most part, with family members seated either at home or in a relaxation room at their place of work or at the hospital. Whilst participants reported the massage as being a restful experience, it is not possible to evaluate whether it was the massage per se that led to the experience of restfulness and improved energy. There is some evidence to suggest that interventions such as group sessions and stress management can also be associated with feelings of relaxation, restfulness and increased activity and energy (Heinrich & Coscarelli Schag 1985, Plant et al. 1987). As such it should perhaps be considered that the experience of rest, and improved energy was a consequence of an enforced period of silent rest rather than being a direct outcome of the massage.

In reading this article, it becomes clear that soft tissue massage was well received by participants in the period shortly after the death of their family member. Whilst this is in no way disputed, it should be recognised that many of the positive outcomes experienced by participants and attributed to soft tissue massage may be experienced to the same extent with an alternative intervention. As discussed earlier, evidence suggests that some of the important components of bereavement support are contact with a health professional, structure and an empathetic approach. Whilst it appears that soft tissue massage fulfils these criteria, there are presumably many other interventions that would fulfil the criteria to the same extent. Interventions such as telephone calls (Kaunonen et al. 2000) and grief therapy (Kissane et al. 2006) include many of the components that soft tissue massage boasts and have been shown in experimental trials to be modestly effective. Alternative bereavement interventions may also have additional benefits. For example, group support sessions and telephone interventions are more cost-effective with lower staffing requirements than individual massage sessions, potentially increasing the appeal for health authorities and policy makers. Evidence also suggests that discussion-based therapies that allow the bereaved family member to talk about their grief have additional benefits. A study evaluating the impact of a supportive telephone call intervention for bereaved family members identified that the opportunity to talk was valued as most helpful by participants (Kaunonen et al. 2000). Carer support groups have also been found to generate positive outcomes as a result of the benefits of information requesting and giving, sharing of practical and coping skills, and social comparison (Harding & Higginson 2003).

The study by Cronfalk et al. contributes to a growing literature in the area of complementary interventions in palliative care and provides valuable qualitative data on the experiences of participants. The advantages of this approach are the insights that are provided into the experiences and perceptions of those involved. However, the lack of outcome evaluations means the effectiveness of soft tissue massage as an early intervention for bereaved relatives cannot be confirmed. Systematic well-controlled strategies are now required in order that therapies such as soft tissue massage are afforded the opportunity to prove, or otherwise, their effectiveness as bereavement support interventions.

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